198602177-6-3-2021-11-AS-EDAT-C3MHZ7-20210603063751

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602177
Report Date: 06/02/2021
Date Signed: 06/03/2021 06:38:27 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME:	LIVE WELL RESIDENTIAL CARE		FACILITY NUMBER:	198602177
ADMINISTRATOR:	ANGULUAN, JOVANNE		FACILITY TYPE:	740
ADDRESS:	211 E CLARION DRIVE		TELEPHONE:	(310) 435-8608
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	6	CENSUS: 6	DATE:	06/02/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:06 AM
MET WITH:	JOVANNE ANGULUAN,		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/02/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with administrator Jovanne Anguluan and explained the purpose of today’s visit. The facility is licensed for six (6) residents and currently has six (6) residents. The facility is licensed for a hospice waiver on file and currently has one (1) resident on hospice. The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) resident's rooms, two (2) common bathrooms, living area, dining area, kitchen, and outside covered patio area. LPA and administrator toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 113.4 F. A comfortable temperature of 73 degrees was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Fire extinguishers were charged, smoke detectors and carbon monoxide were operable. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: LIVE WELL RESIDENTIAL CARE	FACILITY NUMBER: 198602177
	VISIT DATE: 06/02/2021

NARRATIVE

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff surveillance testing and training records was conducted.

Advisory Notes - Technical Assistance was issued, please see LIC9102-AN.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Jovanne Anguluan by email.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

LIC809 (FAS) - (06/04)

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